Provider Demographics
NPI:1285394411
Name:DERBY, MICKAYLA
Entity type:Individual
Prefix:
First Name:MICKAYLA
Middle Name:
Last Name:DERBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 MORGAN RUN RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:WV
Mailing Address - Zip Code:26562-6293
Mailing Address - Country:US
Mailing Address - Phone:304-889-2310
Mailing Address - Fax:
Practice Address - Street 1:937 MORGAN RUN RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:WV
Practice Address - Zip Code:26562-6293
Practice Address - Country:US
Practice Address - Phone:304-889-2310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1356607394Medicaid
WV1821206228Medicaid
WV125553494Medicaid